Biliary diseases Flashcards
What are the three traditional liver function tests
ALT, AST, alkaline phosphate
Alanine aminotransferase (ALT)
released when hepatocytes are hurt or destroyed
Aspartate aminotransferase (AST)
not specific for liver disease because it is found in the heart, intestine and pancreas as well as the liver
When do alkaline phosphate levels rise
when there is obstruction or infiltrative diseases
Where is alkaline phosphate found
liver (biliary tract), bones, intestines, placenta
What is the first enzyme to be detected with damage to the liver
gamma-glutamyl transpeptidase (GGT)
When do you check a GGT level
when you are unsure if the alk phos level is increased because of bone of liver
Where is LDH found? When does it get elevated?
in the blood and liver, gets elevated with tissue damage
What is bilirubin
yellow pigment formed in the liver by the breakdown of hemoglobin and excreted in bile
When is bilirubin elevated
- jaundice
- liver disease and blockage of bile ducts
- any process that breaks down RBCs
- anything that affects the production or destruction of bilirubin
When is unconjugated bilirubin made?
released from hemoglobin and converten, then is carried by proteins to the liver
What makes bilirubin conjugated?
when sugars are attached
What is the path of conjugated bilirubin
enters the bile–>passes from the liver to the small intestine–>eliminated in the stool
Which type of bilirubin can have small amounts in the blood
unconjugated
What is the hepatocellular pattern of liver enzymes? What does that tell you?
increased AST and ALT compared to alk phos
tells you there is an intahepatic injury
What is the cholestatis pattern of liver enzymes?
increase in alk phos compared to AST and ALT
What is isolated hyperbilirubinemia
increase in bilirubin with normal alk phos and AST/ALT
What are some common diseases that show hepatocelluar injury
- viral hepatitis
- drugs/alcohol
- environmental toxins
- autoimmune hepatitis
- wilson disease
- ischemia
What are some common diseases that show clolestatic injury
- primary billiary cirrhosis
- primary sclerosing cholangitis
- cholanglocarcinoma
- pancreatic cancer
- choledocholithiasis
What are the three components of bile
- bile acids
- phospholipids
- cholesterol
What are the primary bile acids? Where are they formed?
colic acid and chenodeoxycholic acid that are formed by cholesterol from the liver and amino acids
What are secondary bile acids?
bacterial metabolites of primary bile acids formed in the colon
What are the functions of bile?
- excrete cholesterol
- aid in the digestion and absorption of fat and cholesterol/fat soluble vitamins in the intestines
How does bile aid in the digestion of fats
forms micells that bind to the fat and aid in absorption through micellar transport mechanism
What is the circulation of bile?
stored in the gallbladder–>absorbed through the gut unconjugated–> bile salts are absorbed in terminal ileum–> secreted back into the bile
What is cholestasis
a blockage of the bile ducts
What types of things can cause cholestasis
- gallstones
- tumors
- cysts
- pancreatic problems
- liver disease
How does a patient with cholestasis present
- RUQ pain
- colicky
- jaundiced
- dark urine
- weight loss
What would the liver enzymes look like in a patient with cholestasis
all be elevated
AST, ALT, alk phos
What other tests should be done if you suspect a patient has cholestasis?
US to look for cause of blockage
CT or MRI to look for liver disease
What is colelithiasis
gallbladder stones
What is the mechanism of gallstone formation
increased biliary secretion of cholesterol–>cholesterol crystals percipitate and form a stone
What are the two types of gallstones? Which is most common?
cholesterol stones (most common) calcium bilrubinate stones
What is biliary sludge? What is its significance?
mucous like supersaturation of bile that is typically a precursor to stones
What are the risk factors for cholelithiasis?
4 F’s
Fat, Fertile, Forty, Fair
How does gallbladder pain present?
pain in RUQ with radiation to the shoulder
Clinical presentation of cholelithiasis
- gallbladder pain with associated N/V
- pain is often post prandial, especially in a meal high in fat
What would the LFTs look like in a patient with cholelithiasis
ideally they would be normal
What tests are done to diagnose cholelithiasis
- ultrasounds
- x ray
- hepatobiliary scan
When is cholelithiasis treated
when a patient is symptomatic
How is cholelithiasis treated
- laparoscopic cholecystectomy
- lithotripsy
- chenodeoxycholic and ursodeoxycholic acid (bile salts)
What is cholecystitis
inflammation of the cyst wall of the gallbladder
What is acute cholecystitis typically caused by
gallstone obstruction
Presentation of acute cholecystitis
- RUQ pain+ murphy’s sign
- guarding
- fever
- leukocytosis
- N/V
- anorexia
What is the difference between acute cholecystitis and acalculus cholecystitis
the presence of gallstones
What is Courcolser’s sign
a palpable gallbladder on physical exam because the gallbladder dilated die to obstruction of common bile duct
What will the LFTs and labs show if a patient has cholecystitis?
WBC, bili, AST/ALT, alk phos, amylase
ELEVATED
Imaging for acute cholecystitis
- RUG ultrasound
- HIDA
What would a RUQ US show if a patient had acute cholecystitis
stones and inflammation of the gallbladder
What would a HIDA scan show if a patient had acute cholecystitis
obstruction in the cystic duct
What is the treatment for cholecystitis?
- lap cholecystectomy
- NPO, IVF, pain control
- IV abx
Which pain medication should you use caution with in a pateint with cholecystitis? Why?
morphine, causes spasm of the sphincter of Oddi
What abx are given to a patient with cholecystitis
3rd gen ceph+ flagyl
in severe cases, fluoroquinolone+flagyl
What are some complications of acute cholecystitis
- gangrene
- emphasematous cholecystitis
- empyema
- chronic cholecystitis
- cholangitis
- hydrops
- porceline gallbladder
What is choledocolithiasis
a gallstone in the common bile duct
What will the LFTs and labs look like in a patient with choledocolithiasis
- extremely elevated AST/ALT
- elevated bili
- slow rise in alk phos
What imaging is done for a patient with choledocolithiasis? What will they show?
RUQ US and CT- dilated ducts
MRCP
ERCP
What is the treatment for choledocolithiasis
sphincterotomy with stenplacement via ERCP
What is a complication of choledocolithiasis
cholangitis
What is cholangitis
inflammation of the bile duct
What is Charcot’s triad
fever, jaundice, severe RUQ pain
What is Reylonds pentad
fever, jaundice, severe RUG pain, hypotension, AMS
How does cholangitis present
- Charcot’s triad
- pruritis
- dark urine
- acholic stools
How do you treat cholangitis
- endoscopic sphincterotomy and stone extraction
- IV abx
- lap cholecystectomy following ERCP
What abx are given to a patient with cholangitis
ampicillin+gentamycin
OR
cipro+flagyl
What is primary sclerosing cholangitis
diffuse inflammation of the biliary system
What can primary sclerosing cholangitis lead to
fibrosis and strictures
What is the clinical presentation of primary sclerosing cholangitis
- progressive obstructive jaundice
- fatigue
- pruritis
- anorexia
- indigestion
What would a patients alk phos look like if they had PSC
elevated
How do you diagnosed PSC
ERCP or MRI
What would a liver biopsy show in a patients with PSC
-periductal fibrosis
What are the complications of PSC
- cholangiocarcinoma
- gallstone
- cholecystitis
- gallbladder polyps
How do you treat acute bacterial PSC
cipro
How do you treat chronic PSC
- balloon dilitation or stenting
- resection of dominant structures
if PSC+ liver cirrhosis–> liver transplant
What is the function of the sphincter of Oddi
prevent reflux of duodenal juices into the pancreatic duct and common bile duct
What role does the pancreas have in digestion
its secretions provide enzymes and bicarbonate needed to affect the major digestive activity
What are the two most common types of acute pancreatitis
- interstitial pancreatitis (most common)
- necrotizing pancreatitis
Causes of acute pancreatitis
- gallstones
- alcohol
- idiopathic
- post ERCP
- smoking
- Rx
- infection
- trauma
Complications of acute pancreatitis
- multisystem organ failure (renal and ARDS)
- ileus
- pseudocyst
- pancreatic necrosis
Symptoms of acute pancreatitis
- mid epigastric pain alleviated by sitting forward
- radiation of pain to back
- N/V
- dyspnea
- anorexia
what are the physical exam findings of mild to moderate pancreatitis
- epigastric tenderness
- jaundice
- nausea
What are the physical exam findings of severe pancreatitis
- tachypnea
- hypoxemia
- hypotension
- Cullen’s sign
- Grey turner sign
What labs are done for acute pancreatitis
- amylase
- lipase
- CBC with diff
- metabolic panel
- LFTs
- LDH
- C reactive protein
- fasting triglycerides
Common imaging done in patients with acute pancreatitis
- abd CT with contrast
- abd US
- MRI
What is the IV contrast used for in a CT scan if done for a patient with acute pancreatitis`
to distinguish necrosis from inflammation
What is needed for a diagnosis of pancreatitis
> 2 of the following:
- midepigastric pain +/- radiation to the back - lipase and/or amylase 3x ULN - CT confirmation
How do you manage a patient with acute pancreatitis
- admit to hospital
- determine underlying cause
- NPO
- IVF
- analgesia
- antiemetic
What scores predict the severity of acute pancreatitis
- Ranson criteria
- Apache II score
- SIRS score
- BISAP
What is chronic pancreatitis
irreversible damage to the pancreas
What histologic abnormality are typically present with chronic pancreatitis
- chronic inflammation
- fibrosis
- progressive destruction of exocrine and endocrine tissue
What causes chronic pancreatitis
- alcohol abuse
- idiopathic
- smoking
- cystic fibrosis
- genetic defects
- autoimmune pancreatitis
What are some complications of chronic pancreatitis
- DM/impaired glucose tolerance
- gastroparesis
- malabsorption
- biliary stricutre
- pancreatic carcinoma
What are the symptoms of chronic pancreatitis
- and pain
- anorexia/weight loss
- maldigestion
- N/V
- steatorrhea
What is the treatment for chronic pancreatitis
- low fat diet
- pain management (challenging)
- whipple
What is diverticulosis
sac like protrusions in the colon
What is a diverticula bleed
painless bleeding of the diverticula
What is diverticulitis
inflammation of diverticulum
How is diverticulosis diagnosed
colonoscopy
What is the most common type of diverticulosis
sigmoid diverticulosis
What are some risk factors for diverticulosis
- age
- constipation
- high fat diet
- obesity/ physical inactivity
- genetics
What studies can provide an incidental finding of diverticulosis
- CT
- MRI
- barium enema
What are some of the complications of diverticulitis
- bowel obstruction
- abscess
- fistula
- perforation
What are the symptoms of diverticulitis
- LLQ abd pain (constant)
- N/V
- fever
- change in bowel habits
What imaging is done to diagnose diverticulitis
CT of abd/pelvis with IV contrast +/- PO contast
What is the medical management for diverticulitis
- abx (coverage for enterobacteriaciae ad gram - anaerobes)
- IVF
- analgesia and antiemetics
When do you need emergency surgery in the case of diverticulitis
if there is a free perforation or large bowel obstruction
When is urgent surgery needed with diverticulitis
- failure of medical treatment
- coloninc obstruction or abscess
When is surgery for diverticulitis elective
- persistent pain
- fistula development
- hx of complicated diverticulitis
- immunocompromised pt with prior acute diverticulitis
What are the options for diverticulitis surgery
One stage procedure: colon resection with primary anastamosis
Two stage procedure: colonic rescection with end colostomy then primary anastamosis with diverting ileostomy
What are the symptoms of a diverticula bleed
- painless hematochezia
- painless maroon color mixed with stool
- bloating, cramping, urgency
How do you diagnose a diverticula bleed
- colonscopy
- nuclear scintigraphy
- angiography
How do you manage a patient with a diverticula bleed
- two large bore IVs with NS
- type and cross for blood
- transfuse PRBCs as needed
- NG tube to r/o UGI bleed
How is active diverticula bleeding treated
submucosal epi or tamponade via endoscopy
When would you do surgical intervention in a patient with a diverticula bleed
- if patient is hemodynamically unstable
- if endoscopic or angiographic therapy is not successful
- patients with recurrent episodes of bleeding
